Provider Demographics
NPI:1821254707
Name:GARY B GRUNDY DC PC
Entity Type:Organization
Organization Name:GARY B GRUNDY DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:GRUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:781-986-4683
Mailing Address - Street 1:24 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4821
Mailing Address - Country:US
Mailing Address - Phone:781-986-4683
Mailing Address - Fax:781-961-4504
Practice Address - Street 1:24 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-4821
Practice Address - Country:US
Practice Address - Phone:781-986-4683
Practice Address - Fax:781-961-4504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA967111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1610422Medicaid
MAT-58332Medicare UPIN
MA1610422Medicaid